The "Childmyths" blog is a spin-off of Jean Mercer's book "Thinking Critically About Child Development: Examining Myths & Misunderstandings"(Sage, 2015; third edition). The blog focuses on parsing mistaken beliefs that can influence people's decisions about childrearing-- for example, beliefs about day care, about punishment, about child psychotherapies, and about adoption.
See also http://thestudyofnonsense.blogspot.com

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Concerned About Unconventional Mental Health Interventions?

Tuesday, May 15, 2018

When Peer Review Fails: With Special Relevance to RAD

The idea of peer-reviewed articles in professional
journals is, or at least was, a helpful way of keeping nonsense and excessive
speculation out of respected print publications. Authors submit articles to
journals, and editors send them on to professionals who are knowledgeable in
relevant fields. Those people, peers of the article authors in that they have
similar training, review the submitted material and convey their conclusions to
the editors. These conclusions may be to reject the article entirely or to
accept it just as it stands, but most often peer reviewers suggest acceptance
with some major or minor revisions. Good reviewers can assess the background of
a submitted article, can understand whether information cited from other work
is correct, can evaluate research methods that were used, and can advise on
improving organization and writing.

This is a lot of work and may or may not be done as
well as we’d like. Not all peer reviews catch problems—and when big problems
remain, journal editors may sometimes have to retract an article that contains
major errors or that is just a repetition of something the author has published
elsewhere.

In addition to the occasionally failures of reviews,
nowadays we have the problem of the ever-expanding number of journals. Some of
these are “predatory” journals whose real purpose is to collect fees from
authors (conventional professional journals do not charge except sometimes for
publication ofillustrations). Some are
“open access” journals that charge fees and provide quick publication for
articles that might not be accepted otherwise, or whose publication might be
delayed longer than is comfortable for an author who is afraid of perishing
without a publication. These journals refer to themselves as “peer reviewed”,
and no doubt someone does “peer” at the submissions, but little effective
reviewing happens.

When predatory or open access journals make mistakes
about accepting articles, those mistakes are rarely corrected. Journals that
take seriously the job of reviewing are likely to retract wrong articles or
publish corrections—or, they very quickly publish additional articles
critiquing the problem material. For example, the journal Child Development, which is about as serious and respectable as a
publication can get, recently published a piece claiming that exposure to
wireless technologies has been shown to affect child development (Sage, C.,
& Burgio,E. [2018]. Electromagnetic fields, pulsed radiofrequency
radiation, and epigenetics: How wireless technologies may affect childhood
development. Child Development, 89,
129-136). Interestingly, when this article was published on line, it did not
include a conflict of interest statement, which was added for the print
version, as one of the authors is the owner of an environmental consulting firm
and a consultant on relevant policy and decisions.

When the Sage and Burgio article appeared on line, it
was seen by others than the original reviewers, and these people were able to
recognize that the authors had “cherry-picked” and misrepresented material. Two
authors submitted a commentary that the journal published in the same print
edition as the Sage and Burgio article—the commentary stating that “these
claims are devoid of merit, and… should not have been given a scientific veneer
of legitimacy” (Grimes, D., & Bishop, D. [2018]. Distinguishing polemic
from commentary in science: Some guidelines illustrated with the case of Sage
and Burgio [2017].) Grimes and Bishop stated that it was their view “that this
piece has potential to cause serious harm, and should never have been
published.” They followed this statement with a suggested series of questions
to be used by readers and reviewers in ascertaining whether an article deserves
publication or should be regarded as credible. Among these questions, all of
which deserve real attention, were four of particular interest: 1. Is there a
plausible mechanism for a claimed effect? 2. Does evidence come from
[genuinely] peer-reviewed sources? 3. Are all relevant studies considered? 4.
Are results of specific studies misrepresented?Applying their list of questions, Grimes and Bishop were able to show
that the Sage and Burgio paper was completely unacceptable. However, because the
paper was not actually retracted, Sage and Burgio may (unfortunately) continue
to argue that their work was validated by its acceptance by a prestigious
peer-reviewed journal.

In the title of this post I said we would get to
Reactive Attachment Disorder, and I am about to do that, with a description of
an article that probably should not have been accepted by a journal and of
another article that critiqued the first one. The problematic article was an
effort to argue that difficult and oppositional behavior, conduct disorder, and
callous-unemotional traits are closely associated with RAD (Mayes, S., Calhoun,
S., Waschenbusch, D., Breaux, R., & Baweja, R. [20i7]. Reactive
attachment/disinhibited social engagement disorders: Callous-unemotional traits
and comorbid disorders. Research in
Developmental Disabilities, 63, 28-37).

A little history is needed to understand the
background of the Mayes et al article. Definitions of RAD have changed over the
years, beginning in 1980 with the idea that the disorder involved infant
failure to thrive and gradually changing to comprise unusual behaviors of young
children toward adult caregivers. Until recently, RAD was considered to exist
in two forms, an inhibited form in which young children did not seek care or
comfort from adults, and a disinhibited form in which young children were as
likely to approach strange adults as to approach familiar people for care and
social interaction. The 2013 version of the Diagnostic and Statistical Manual
of Mental Disorders (DSM) separated the inhibited version, which kept the term
RAD, from the disinhibited version, which now became Disinhibited Social
Engagement Disorder (DSED).

Meanwhile, however, there had been as far back as the
1990s an effort to create an alternative view of a disorder attributed to early
separations, abuse, and neglect. This putative disorder was often referred to
as Reactive Attachment Disorder, but instead of involving unusual social
behavior toward caregivers, it was said to include disturbing aggressive behaviors
like cruelty, theft, lying, and “fascination with blood and gore”. Some
alternative practitioners claimed that they had discovered a new form of the
disorder, not Reactive Attachment Disorder at all, but something they called
simply Attachment Disorder. This notional diagnosis was promulgated by
practitioners of Holding Therrapy/Attachment Therapy, by a number of adoption
groups, and by support groups for adoptive parents. The idea of violent
Attachment Disorder behavior was taught by made-for-TV movies like “Child of
Rage” and by various related websites. For a number of years, newspaper
articles about child abuse have often proposed that abused children showed
disturbing behaviors said to be characteristic of RAD or AD and in some sense
had forced adults to mistreat them. These beliefs continue to be promulgated,
as can be seen at https://blogs.psychcentral.com/childhood-behavioral/2018/05/why-parents-of-r-a-d-children-always-look-like-aholes/, a blog where commenters claim
that adoptive parents of children “diagnosed with RAD” and behaving aggressively
must treat those children as coldly and mechanically as possible. In reply to
criticism of this position, comments are focused on the idea that anyone who
does not think RAD includes callous-unemotional or aggressive behavior has
simply never lived with such a child—a rather inconsequential response, as no
one has said that their children do not display the claimed behaviors, just
that these are not evidence of RAD.

Conventional, evidence-based work on childhood mental
illness has rejected the idea that externalizing behavior, conduct disorders,
or callous-unemotional characteristics such as lack of empathy are related to
attachment experiences or should be treated by methods that stress attachment.
The article by Mayes et al argues against that conventional view and presents a
small amount of data that are used to conclude that children diagnosed with RAD
are also likely to be violent, cruel, callous, and unemotional. The study
examined 20 children, ages 4-17, who had been diagnosed with RAD or DSED or
both, and compared them with much larger groups of children diagnosed as
autistic or as having ADHD. The authors suggested that the DSM discussion of
RAD should include references to conduct disorders and callous-unemotional
traits as associated with RAD.

A trenchant response by a competent critic of misused
attachment concepts followed the Mayes et al paper (Allen, B. [2018]. Misperceptions
of reactive attachment disorders persist: Poor methods and unsupported
conclusions. Research in Developmental
Disabilities, 77, 24-29). In keeping with our concern with failed peer
review, Allen offered guidelines for reviewing articles that stress attachment
issues. He used the Mayes paper as an example of a publication about which
reviewers had not asked the right questions.

Here are the questions Allen suggested as review guidelines:

1.How well is attachment research
reviewed? This is an area where, Allen suggests, Mayes et al
seem to have “cherry-picked”, stressing early writings of John Bowlby and
omitting some of the contradictory conclusions of his later work.

I would like to add that
Mayes et al used a 2003 paper by Hall and Geher to support the claim of
aggressive externalizing behavior in children with RAD; the Hall and Geher
paper in turn was dependent on what may be the ur-article on such behavior in children diagnosed with RAD, an
obscure publication, probably not peer-reviewed in any real sense, that put
forth the idea that RAD children can vomit or defecate at will and do so simply
to antagonize their caregivers (Reber, K. [1996]. Children at risk for
attachment disorder: Assessment, diagnosis, and treatment. Progress: Family Systems Research and Therapy, 5, 83-98 ; this
publication of a freestanding California institute used to be available on the
Internet but I have not been able to find it recently). (Reber’s claims may
have been behind the Internet arguments that Candace Newmaker died
intentionally in order to cause trouble for the therapists who asphyxiated
her.) The influence of Reber on Hall and Geher and subsequently on Mayes et al
demonstrates that reviewers need to be aware not only of the background
publications being cited in an article, but also of the nature of the material
cited in those publications.

2.Are
attachment constructs clearly defined? Unfortunately, attachment
concepts seem to have achieved the position of obscenity, in that most people
can’t define them but believe they know them when they see them. Nonetheless,
as Allen suggests, it is crucial to know whether authors are concerned with
attachment behavior, attachment representations, or attachment theory. The
choice of constructs is directly related to understanding of how a diagnosis
was made—a point left obscure in the Mayes et al paper.

3.Are
assessment measures and methods clearly specified? All
too often, discussions of RAD have involved “validation” of assessment methods
against the intuition or “practice wisdom” of one or two clinicians. Elizabeth
Randolph’s Randolph Attachment Disorder Questionnaire (RADQ) is described by
its author as substantiated in part by her ability to diagnose an attachment
disorder when a child cannot crawl backward on command.

Unspecified and vague
assessment measures in the Mayes et al paper are especially important because
of the age range of children examined—from 4 to 17 years of age, with a mean
age about 10. Although toddlers can be expected to reveal the quality of their
attachment to caregivers by their behavior with strangers or when separated
from familiar people, this can hardly be expected with school-age children or
teenagers, whose cognitive and emotional development and daily experiences
allow them to handle separation or contact with strangers as normal events that
affect their behavior very little. Assessments of 4-year-olds, 10-year-olds,
and 17-year-olds can hardly take the same forms, yet Mayes et al do not state
differences in evaluation of children of different ages, and ignore the many
discussions in the literature about the maximum age at which RAD could be a
meaningful diagnosis.

4.Do the authors use tautological
reasoning? When clinicians believe that RAD involves
aggressive or callous-unemotional traits, they may use such traits as a reason
to diagnose RAD, even though RAD by definition does not include these traits. Allen
queries whether this illogical approach is responsible for the conclusions
drawn by Mayes et al.

Historically, proponents
of the idea that externalizing problems were part of attachment disorders have
also arguedthat children with
problematic attachment histories (separation, abuse, neglect) will of necessity
have RAD and [therefore] externalizing problems, such a history being in the
past a factor in the RAD diagnosis; this claim was even applied when children
showed no behavioral disturbance, with convinced clinicians telling parents
that the child’s normal behavior was simply an indication of the degree of
disturbance, intended to lull the parent’s concerns until the child found a way
to attack effectively.

5.Do the authors make remarkable
conclusions, which may not be supported by their data?
Allen suggests that mistaken conclusions are drawn by Mayes et al, for example
that it is incorrect to claim that RAD is associated with internalizing
problems and DSED with externalizing problems (e.g., cruelty, lack of empathy),
even though this is what otherunemotional traits, the Mayes et al conclusions fail to recognize the
limitations of their studyas stated
above and discussed in the Allen paper.

It is clear that if
reviewers had used the questions supplied by Allen in their reviews of the
Mayes et al paper, the paper would never have appeared except in a considerably
revised form.

Revisions would also have
been required for publication if the guidelines proposed by Grimes and Bishop
(2018), some of which were discussed earlier in this post, had been applied.
The plausible mechanism demanded by Grimes and Bishop is certainly missing in
the Mayes et al article—by what mechanism would a failure of attachment lead to
cruel and callous-unemotional behavior posited by Mayes, or the disobedience,
ingratitude, and lack of remorse claimed by Randolph and others? Attachment
theory and the idea of attachment representations, with their stress on
cognitive and social development, do not provide any explanation of the
proposed mechanism.

A question about causal
claims put by Grimes and Bishop would also require Mayes et al to revise their
article and supply a much elaborated discussion of limitations. This
nonrandomized study design does not allow for the stated conclusion that externalizing
behaviors are caused by problematic attachment histories.

There is little question
that guidance is needed by peer reviewers dealing with submitted papers
involving the complexities of attachment concepts and the conflation of
established views of attachment with alternative attachment theories. Given the
approaches proposed by Allen and by Grimes and Bishop, we can hope, along with
Allen, that “through this
process of enhanced scrutiny of papers examining RAD/DSED that misperceptions
and subsequent substandard clinical services can be significantly
improved.”

About Me https://en.wikipedia.org/wiki/Jean_Mercer

Jean Mercer has a Ph.D in Psychology from Brandeis University, earned when that institution was 20 years old (you do the math). She is Professor Emerita of Psychology at Richard Stockton College, where for many years she taught developmental psychology, research methods, perception, and history of psychology. Since about 2000 her focus has been on potentially dangerous child psychotherapies, and she has published several related books and a number of articles in professional journals.
Her CV can be seen at http://childmyths.blogspot.com/2009/12/curriculum-vitae-jean.mercer-richard.html.